Preparedness of Pakistan in view of monkeypox emergence: a call for action
Authors: Javeria Arif Siddiqui, Humna Aamar, Aiman Rija, Mohammad Yasir Essar
Journal: International Journal of Surgery (2023)

Dear Editor, Now declared a global health emergency by the WHO, monkeypox (MPX) has been reported in more than 90 nonendemic countries, with over 77 080 confirmed cases as of 28 October 20221. Although no cases have been detected in Pakistan so far, neighbouring countries like India, reported 12 cases and one death due to MPX, as of 5 September 20221. Further outbreaks in the WHO South East Asia region have been reported since 18 August 2022, and thus the risk of an outbreak of MPX in Pakistan must be taken seriously2. As a low-middle-income country with a weak healthcare system, still battling diseases like polio, Pakistan must be prepared with a practical approach and action plan to tackle this potential outbreak of MPX3. MPX is a virus, from the Orthopoxvirus genus in the family Poxviridae, first occurring in Africa in 19704. It can be transmitted from contact with an animal, human, and contaminated objects5. It enters the body through torn skin, and the respiratory tract. Animal-to-human transmission is carried out by a bite, scratch, direct contact with bodily fluids or lesion, or indirect contact with lesion5. Human-to-human transmission is carried out mainly by large respiratory droplets through prolonged face-to-face contact, though the other methods can cause transmission as well5. Once the virus is transmitted, the illness begins with fatigue, fever, chills, and body aches, similar to smallpox6. Characteristically, the infection causes lymphadenopathy, differentiating MPX from smallpox, and lesions5,6. In recent cases, the rashes have been mainly in the urogenital region, but can be all over the body5,6. MPX has an incubation period of 1–2 weeks and the illness lasts for 2–4 weeks5,6. It can be diagnosed based on the symptoms and rash, but laboratory tests such as PCR, enzyme-linked immunosorbent assay, virus isolation, electron microscopy, and immunofluorescent antibody assay can be confirmatory. Once confirmed, treatment of MPX includes the smallpox vaccines (e.g. JYNNEOSTM and ACAM2000) or administration of antiviral drugs, such as Tecovirimat, Cidofovir, Vaccinia Immune Globulin Intravenous (VIGIV), etc., though there is no approved treatment method5,6. Smallpox vaccines only have 85% effectivity and one in 10 cases results in death6. Therefore, preventing the contraction of the virus would be better than treatment. Prevention methods include isolation, hand hygiene, and avoidance of touching contaminated objects and contact with infected animals5. Recently, MPX has been reported in nonendemic areas and news about MPX has been circulating on social media, putting countries like Pakistan on high alert4. The provincial health department has begun to take precautions and airport restrictions have been implemented7. Primary healthcare is available to the whole urban population and 70% of the rural population8. Pakistan has implemented the national policy of health, which is committed to improving quality of life through physical, social, and mental health and a plethora of preventive health initiatives like the Expanded Program of Immunization, the National TB control program, family planning program and school nutrition programs8. Though such actions ensure a healthier future for the people of Pakistan, the healthcare system of Pakistan is far from perfect. Pakistan has suffered from multiple endemics of dengue, malaria, polio, and more recently, COVID-19. While polio vaccination has been included in the Expanded Program of Immunization (EPI) and been significantly reduced, the rest still play a major role in illness. These health issues have exacerbated the healthcare capacity in Pakistan, and a lack of financial resources has made it difficult to obtain adequate manpower, ventilators, hospital beds, and laboratory equipment, making prevention of the spread of MPX critical4. Pakistan is short of diagnostic facilities like MPX testing kits7. Since Pakistan has a centralized health system, major health decisions lie in the federal government’s hands, while the provincial government has the authority to implement the plans, but due to a communication gap, there is lack of implementation, duplication of resources and many programs have no resolution. This results in the inefficiency of the system and compromised quality of healthcare, which further develops distrust between the people and the healthcare system. This distrust decreases people’s willingness to go to healthcare providers and increases the risk of infection8. This distrust also stems from the lack of health equity between the poor and rich, as rural areas have poor healthcare infrastructure and while primary healthcare facilities are present, they are nonfunctioning due to absence of healthcare staff8. Poor infrastructure of such facilities results in overcrowding at major hospitals8. The staff also face issues, due to cultural and language barriers, considering people hailing from different regions of Pakistan have different beliefs and dialects8. The population themselves are also at higher risk of contracting MPX as smallpox vaccinations were ceased in the late 90s, thus, present populations have a waning immunity to MPX7. COVID-19 also affected people’s immune system by reducing number of their dendritic cells, making them more vulnerable to secondary infections7. Therefore, though no cases of MPX have been reported in Pakistan since 29 May 2022, a MPX outbreak is still a concern as Pakistan does not have the finances, supplies, and infrastructure to control this outbreak7. In July 2022, when the WHO termed the MPX outbreak as a global health emergency, the Minister for National Health Services (NHS), Pakistan directed all the hospitals and relevant authorities to adopt prompt measures to deal with the virus spread9. Currently, Pakistan lacks any diagnostic facility for MPX, and thus, current policies mention the recommendation of sending samples abroad for testing if needed4,10. Physicians’ knowledge about the MPX virus is considered pivotal in controlling the spread of an infectious disease in a developing country like Pakistan4. The healthcare workers should be well aware of the presenting signs and symptoms, and be trained to follow the history-taking protocol that enables the tracking of travel history, origin of virus, and people in close contacts4. In addition, the systematic approach of adopting the recommended quarantine and treatment guidelines for MPX Patients would not only benefit infected patients but could also rule out potential, asymptomatic, and suspected cases. Government and healthcare authorities should ensure the enforcement of mandatory screening at the airports, and the devising of the national policies for MPX for the public4,11. Awareness sessions and campaigns should be especially structured and regularly held, with the aim of familiarizing the population with preventive measures, such as social distancing, limiting sexual intercourse, and the maintenance of proper hygiene12. Educational programs imparting accurate information about the symptoms, treatment and the moderate course of MPX infection would help reconstruct the misleading concepts prevalent among the masses13. Access to healthcare facilities and screening procedures, coupled with a guide to effectively report symptoms and seek help would enable people to feel empowered to combat the uncertain situation of MPX virus at hand. For future prospects, carrying out vaccination drives, establishing screening clinics, and improving surveillance strategies are significant recommendations. One of the effective interventions is the ring-vaccination protocol, which targets vulnerable individuals possibly exposed to an infected person at some point in time11. To conclude, although Pakistan still has not had a confirmed case of MPX, the threat of an outbreak remains imminent. The weak healthcare infrastructure combined with lack of training and awareness in Pakistan increases the risk of undetected MPX infections spiralling into major outbreaks. Therefore, a practical action plan must be devised and implemented to prepare Pakistan for this potential burden. Ethical approval None. Sources of funding None. Author’s contribution M.Y.E.: conceptualization and review and editing. J.A.S., H.A., and A.R.: writing original draft. Conflicts of interest disclosure The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) None. Guarantor Mohammad Yasir Essar.